Subclinical Cerebral Edema in Children With Diabetic Ketoacidosis Randomized to 2 Different Rehydration Protocols

Abstract

WHAT'S KNOWN ON THIS SUBJECT: Cerebral edema (CE) occurs frequently during treatment of diabetic ketoacidosis (DKA) in children. Severe, life-threatening CE occurs rarely, but subclinical CE is common. Whether the rate of infusion of intravenous fluids influences the occurrence or severity of CE is unknown. WHAT THIS STUDY ADDS:This study demonstrates that the rate of fluid infusion in children with DKA does not substantially affect MRI measures of CE. Studies assessing measures other than edema formation are necessary to determine whether fluid infusion rates influence DKA-related brain injury.abstract OBJECTIVE: Previous studies show that vasogenic cerebral edema (CE) occurs during diabetic ketoacidosis (DKA) treatment in children, but the role of intravenous fluids in contributing to CE is unclear. We used magnetic resonance diffusion weighted imaging to quantify subclinical CE in children with DKA randomized to 2 intravenous fluid regimens. METHODS:Children with DKA were randomized to receive fluids at a more rapid rate (n = 8) or a slower rate (n = 10), with all other aspects of DKA treatment kept identical. Children underwent diffusion weighted imaging 3 to 6 hours and 9 to 12 hours after beginning DKA treatment and after recovery from DKA ($72 hours after beginning treatment). We calculated brain apparent diffusion coefficient (ADC) values as the average of measurements in the basal ganglia, thalamus, frontal white matter, and hippocampus and determined the mean brain ADC value during DKA treatment by averaging data from the 3-to 6-hour and 9-to 12-hour measurements. The difference in mean brain ADC between DKA treatment and postrecovery was used as an index of the severity of CE during DKA treatment.RESULTS: Mean brain ADC values during DKA treatment were significantly higher than postrecovery values, consistent with vasogenic CE (842 6 38 vs 800 6 41310 -6 mm 2 /second, P = .002). We did not detect significant differences in ADC elevation in children treated with more rapid versus slower rehydration (b coefficient 0.11 for 1 SD change in ADC, 95% confidence interval: -0.91 to 1.13).CONCLUSIONS: ADC changes during DKA treatment (reflective of vasogenic CE) do not appear to be substantially affected by the rate of intravenous fluid administration. Pediatrics 2013;131:e73-e80 AUTHORS: